Doctors shocked as neuroscientist ‘talks’ with man in vegetative state

Scott Routley, man in vegetative state, talks to doctors after five years

For more than a decade, Scott Routley remained in what doctors considered a vegetative state, awake but unable to move a muscle and seemingly unaware of life around him after the car crash that severely damaged his brain.

Then this spring a British neuroscientist conducted a remarkable experiment during which he says he was able to communicate with the London, Ont., resident, asking if Mr. Routley was feeling any pain. The answer, conveyed through brain activity detected on sophisticated MRI scans, was a reassuring “No.”

The just-revealed research, touted as a world first, not only shocked the patient’s long-time neurologist — who assumed his patient’s mind was all but blank — but could further alter scientists’ understanding of people likened, even by medicine, to vegetables.

The latest advance by Dr. Adrian Owen opens the door to numerous possibilities, from stimulating seemingly vegetative patients with talking books, to asking their dining preferences or finding out how aggressively they want to be treated, experts say.

“We now have very clear examples of patients who appeared to everybody, to any form of clinical investigation, to be in a vegetative state, yet with fMRI we’re able to show there’s much more going on,” said Dr. Owen in an interview from his office at the University of Western Ontario.

“It’s not the case that all vegetative patients are conscious, by any means. Most of them probably are what they appear to be. But there are some who we are failing to detect. … What you see is not always what you get.”

Patients in a vegetative state are awake — their eyes open — but are considered unaware, incapable of responding to stimuli or thinking. Some emerge eventually from the state to higher levels of consciousness, while others remain unchanged for years in a permanent vegetative state.

The British scientist, recruited from Cambridge University by Western last year with the help of federal-government funding, has developed techniques for testing whether, in fact, permanent vegetative patients have cognitive abilities and can answer questions. Previous research on small groups of patients suggests as many as one-fifth of them do possess that level of consciousness.

Patients are instructed to imagine moving their arm as if swinging at a tennis ball to answer No, and visualize walking through their homes to answer Yes. Those thoughts cause different regions of the brain to “light up” on functional MRI (fMRI) machines, which capture brain activity over time.

They are first asked yes-and-no questions to which the researchers know the answers — such as whether they have brothers and sisters — to verify the process is working. Mr. Routley, 39, was the first patient to whom Dr. Owen and colleagues were able to successfully pose a clinically relevant question: Are you in pain?

Responses from another Canadian vegetative patient, Steven Graham, suggested some can even gain memories. He was able to correctly answer Yes when asked if his sister had a daughter, though his niece was born after his brain injury five years ago.

It’s not the case that all vegetative patients are conscious, by any means. Most of them probably are what they appear to be

Dr. Bryan Young had cared for Mr. Routley for a decade at London’s Parkwood chronic-care hospital and said he was absolutely convinced, based on standard behavioural tests, that his patient had no intellectual awareness. The results of the MRI scans “changes our understanding” of the condition, said the neurologist.

Mr. Routley’s parents had always been convinced he was cognizant behind the immovable facade, and acted accordingly, but not all vegetative patients are treated that way, said Dr. Young.

“It would be nice to know if there are abandoned people out there who are really aware, who could benefit from some stimulation,” he said. “We probably owe it to people.”

The latest work by Dr. Owen has not yet been published in a peer-reviewed journal, but was revealed in a documentary aired Tuesday by the BBC Television program Panorama, whose crew tracked the research for two years.

His work on cognition in vegetative patients, which first came to prominence with a highly publicized 2010 study, is “very intriguing,” said Dr. Abraham Snaiderman, head of the neuropsychiatry clinic at the Toronto Rehab Institute. But he cautioned against assuming too much about the patients’ level of awareness, given the small sample Dr. Owen has studied and the limitations of his methods.

“Philosophically and ethically, there are serious implications that need to be considered,” said Dr. Snaiderman in an email response to questions. “Is a patient competent to decide about self care if he/she shows fMRI responses to a series of questions? I know many cases where there is recovery of awareness and full consciousness after a severe brain injury, yet the patient remains incompetent to self care and decide about issues related to it.”

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